I always thought if surgeron excised an epidermal cyst its integumentary section but this operative report has me wondering because of what he stated -all way down to the prevertebral fascia. Doctor office insist to to code it as 21932- excision of tumor-soft tissue, but this a cyst (706.2) s not a tumor , so this brings me back to 11406, what do you think ?- Thank you
POSTOPERATIVE DIAGNOSIS: Recurring posterior thorax epidermal inclusion cyst.
PROCEDURE PERFORMED: Excision of mass greater than 5 cm.
PROCEDURE IN DETAIL: After appropriate informed consent was signed, the patient was taken to the operating room and was transferred to the operating table, intubated, and placed in the prone position. The patient received prophylactic antibiotics prior to skin incision. The previous epidermal inclusion cyst had been excised and drained by me on two occasions. The entire incision was made with a knife for about 5 to 6 cm and dissected down through the skin and subcutaneous tissue. A cyst cavity was identified. The entire cyst cavity was then excised with the surrounding fat all the way down to the prevertebral fascia. This was sent to pathology for permanent section. The area was irrigated. There were small skin edges that were cleaned up with Bovie cauterization. The wounds were then closed with 3-0 nylon in horizontal mattress fashion. A sterile dressing was placed. The patient tolerated the procedure well and was transferred to recovery room in stable condition.
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